I. Introduction: Communicable Diseases/Conditions and Return to Childcare .......................... 4

II. General Information ................................................................................................................ 5

III. Attendees ................................................................................................................................. 6

IV. Staff ......................................................................................................................................... 6

V. Exclusion Criteria .................................................................................................................... 7

VI. Chickenpox (Varicella) ............................................................................................................ 9

VII. Shingles (Varicella Zoster) ...................................................................................................... 9

VIII. Cytomegalovirus (CMV) ..................................................................................................... 10

IX. Diarrheal Diseases. ................................................................................................................ 10

X. Shigatoxin producing E. coli (STEC), including E.coli O157:H7 ....................................... 11

XI. Fifth Disease (Erythema Infectiosum) ................................................................................... 12

XII. “Flu” (Influenza) .................................................................................................................... 12

XIII. Hand – Foot and Mouth Disease .......................................................................................... 13

XIV. Head Lice ............................................................................................................................. 13

XV. Hepatitis A ............................................................................................................................. 14

XVI. Hepatitis B ...................................................................................................................... 15

XVII. Hepatitis C ...................................................................................................................... 15

XVIII. Human Immunodeficiency Virus (HIV) Infection/Acquired Immunodeficiency Syndrome (AIDS) ......................................................................................................................... 15

XIX. Impetigo ......................................................................................................................... 16

XX. Measles .................................................................................................................................. 16

XXI. Meningitis....................................................................................................................... 17

XXII. Molluscum Contagiosum ............................................................................................... 17

XXIII. Mumps ............................................................................................................................ 18

XXIV. “Pink Eye” (Conjunctivitis) ........................................................................................ 18

XXV. Pinworms ........................................................................................................................ 18

XXVI. Respiratory Syncytial Virus (RSV) ............................................................................ 19

XXVII. Ringworm ................................................................................................................... 19

XXVIII. Scabies ........................................................................................................................ 20

XXIX. “Staph” (Staphylococcal Infections) .......................................................................... 20

XXX. “Strep Throat” (Streptococcal Pharyngitis) & Scarlet Fever ......................................... 21

XXXI. Tuberculosis (TB) ....................................................................................................... 21

XXXII. Whooping Cough (Pertussis) ...................................................................................... 21

XXXIII. Permission to collect stool specimens and receive test results ................................... 23

XXXIV. Mississippi State Department of Health Public Health Districts ................................ 24

A. Appendix A: Recommendations for the Control of Head Lice in the Childcare Setting 25

I. Introduction: Communicable Diseases/Conditions and Return to

Childcare Child care providers frequently must make decisions regarding when children with communicable diseases/conditions should be allowed to attend or return to the out-of-home child care setting (any center or private residence providing care for more than one child). We hope the information provided in this booklet will help with these decisions. It contains information about the most common or important communicable diseases/conditions and how they are spread. Information is listed about the different times during which infectious agents may be transmitted from one person to another, and when it is usually safe for someone who has one of these conditions to return to the child care setting. The “return to child care times” are based on the usual period of time that a person is considered to be contagious, not on the period of time that may be necessary for full clinical recovery from the signs or symptoms of an illness, which may vary a great deal from person to person. While this booklet will serve as a guide for child care attendance of children with communicable conditions, the Mississippi State Department of Health (MSDH) welcomes the opportunity to help with your decisions. You may contact your local district health department office (available at: http://msdh.ms.gov/msdhsite/_static/resources/3468.pdf or the MSDH Office of Epidemiology at 601-576-7725 to speak with a consultant. ****

***THIS booklet is NOT intended to be used to DIAGNOSE an illness or infection. It SHOULD NOT REPLACE a diagnosis by trained MEDICAL personnel**

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II. General Information Small children who are cared for in out-of-home group settings are at a greater risk of acquiring and spreading a contagious disease. Small children are highly susceptible to contagious diseases since most of them have not been exposed to many of the most common germs and therefore do not have any immunity to them. Young children also have certain habits (e.g., putting their fingers and other objects in their mouths) that can easily spread germs. Even though contagious diseases/conditions will occur in a child care setting, the child care provider should do everything he or she can to prevent and control the spread of disease. The use of common-sense hygienic practices, especially frequent and thorough hand washing cannot be stressed enough! Also, making sure that staff and children are up to date on their immunizations helps to lessen the risk of exposure to contagious diseases. Reportable diseases: Class 1 reportable diseases are those of major public health importance, and are separated in to Class 1A and Class 1B to align with the urgency of a required public health response. Class 1A diseases are to be reported directly to the MSDH by telephone within 24 hours of knowledge or suspicion. Class 1B conditions are to be reported by telephone within one business day after first knowledge or suspicion. Suspected or confirmed outbreaks, regardless of the etiology, are Class 1A reportable conditions. These are typically reported by a physician, hospital or laboratory personnel. However, MSDH encourages childcare staff who know of a child in their facility who has been diagnosed with a disease such as meningitis or measles to report it to the Health Department. This can sometimes help to expedite the investigation. Class 2 and 3 diseases may require public health intervention also, especially if there are several cases in one room (e.g., diarrheal diseases such as Shigella or Salmonella). When a Class 1 reportable disease is reported to the MSDH, there will be an investigation. The immediacy of the response by the MSDH and the extent of the investigation is dependent on the disease. For example, if a child has been reported to have meningococcal meningitis, an investigation would take place as soon as the report is received. It is the goal of the MSDH to provide preventive medication to those for whom it would be indicated within 24 hours of receiving the report. The current list of reportable diseases and conditions is located on the MSDH website (http://msdh.ms.gov/msdhsite/_static/resources/877.pdf). Outbreaks/parental permission for laboratory tests: During times when there are outbreaks of gastrointestinal infections, stool specimens may be requested by the MSDH. The MSDH recommends that child care facilities obtain permission from parents or guardians at the time of enrollment for the child care facility to collect these stool specimens and receive the laboratory results if and when such an outbreak occurs. These laboratory tests would be done by the MSDH Public Health Laboratory free of charge. The laboratory test results would be sent to the child care facility and given to the parents/guardians by the child care facility for them to give to the child’s physician. (See sample permission slip in section XXXIII: Permission to collect stool specimens and receive test results.)

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III. Attendee Immunizations The MSDH regulations governing the licensure of child care facilities mandate that each child in a licensed facility have immunizations according to the recommended immunization schedule. These children are to be age-appropriately immunized and must have a Certificate of Immunization Compliance (Form 121) or a Certificate of Medical Exemption (Form 122) on file at the child care facility and readily accessible for review by the MSDH. The Form 121 must be signed by the District Health Officer, a physician, nurse or designee. The medical exemption, Form 122, MUST be signed by the District Health Officer. Children enrolled in licensed child care facilities and public and private schools in Mississippi may be exempt for medical reasons only. Children usually begin their routine immunizations between 6 weeks and 2 months of age. The immunizations that are currently required at the age-appropriate times for child care are: DTaP (diphtheria, tetanus, pertussis), polio, MMR (measles, mumps, rubella), Hib (H. Influenzae type b), Hepatitis B, and varicella (chicken pox) and pneumococcal vaccines. Child care vaccine requirements may be accessed at: http://msdh.ms.gov/msdhsite/_static/41,0,71,303.html.

IV. Staff Immunizations Anyone (whether full or part-time and even if they are the owner/director) who works in a licensed child care facility must have a Certificate of Immunization Compliance (Form 121) or a Certificate of Medical Exemption from Immunization Requirements for Adults (Form 132) on file and readily accessible for review by the MSDH. The requirement for adults is that they must show proof of immunity to measles (rubeola or “red” measles) and rubella (“German “or “3-day” measles). Proof of immunity to measles: Persons born prior to 01-01-1957 are assumed to have natural immunity to measles. Persons born on or after 01-01-1957 must show proof of immunity in one of the following ways: 1. Serological (a blood test) confirmation of measles immunity. 2. A record of 2 doses of measles-containing vaccine (usually given as MMR) given on or

after the first birthday and on or after 01-01-1968. There must be a minimum time interval of 30 days between the 2 doses.

Proof of immunity to rubella: All child care workers, regardless of age, must show proof of immunity to rubella in one of the following ways: 1. Serological (blood test) confirmation of rubella immunity.

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2. A rubella vaccination received on or after 12 months of age and on or after 01-01-1969. The MSDH does not provide serological testing for measles and rubella for the purpose of child care/school attendance or private employment. Those who wish to have a blood test for proof of immunity to measles and/or rubella should see their private physician. The Child Care Licensure Division of the MSDH checks the immunization records in child care facilities during regular program reviews. District Immunization Representatives also visit child care centers on a random basis to inspect the immunization records of the children and the employees. The purpose of these visits is to verify the presence of the Certificates of Immunization Compliance. These visits also help to ensure adequate immunization of children enrolled in child care facilities

V. Exclusion Criteria Small children can become ill very quickly. The child care provider should observe each child’s health throughout the time the child is in their care. If the child care provider observes signs and symptoms of illness that would require removal from the facility, he/she should contact the parents/guardians to have the child picked up and continue to observe the child for other signs and symptoms. If the child is not responding to you, is having trouble breathing, or is having a seizure or convulsion, call 911. The following conditions require exclusion from child care: Fever: Defined as 100°F or higher taken under the arm, 101°F taken orally, or 102°F taken rectally. For children 4 months or younger, the lower rectal temperature of 101°F is considered a fever threshold. Diarrhea: Three or more episodes of diarrhea in a 24 hour period, that is runny, watery, or bloody. According to CDC recommendations, a child who is not toilet trained and has diarrhea should be excluded from child care settings regardless of the cause. Vomiting: Two or more times in a 24 hour period Rash: Body rash with a fever Sore throat: Sore throat with fever and swollen glands Severe coughing: The child gets red or blue in the face or makes high-pitched whooping sound after coughing.

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Eye discharge: Thick mucus or pus draining from the eye Jaundice: Yellow eyes and skin Irritability: Continuous irritability and crying

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VI. Chickenpox (Varicella) Chickenpox is a highly infectious viral disease that begins with small red bumps that turn into blisters after several hours. The blisters generally last for 3-4 days and then begin to dry up and form scabs. These lesions (bumps/blisters) almost always appear first on the trunk rather than the extremities. Mode of transmission: Airborne droplets of nose and throat secretions coughed into the air by someone who has chickenpox. Also by direct contact with articles freshly soiled with discharge from the blisters and/or discharge from the nose and mouth (e.g., tissues, handkerchiefs, etc.). Notification: Notify parents/guardians and staff members that a case of chickenpox has occurred, especially those parents whose child is taking steroid medications, being treated with cancer or leukemia drugs or has a weakened immune system for some reason. Staff members who are pregnant and have never had chickenpox disease or the chickenpox vaccine should consult their physician immediately. A special preventive treatment may be indicated for those with a weakened immune system and non-immune pregnant women. This treatment must be given within 96 hours of the exposure to be effective. Vaccine: A vaccine for chickenpox is available and is recommended for children after 12 months of age and adolescents and adults who do not have a reliable history of chickenpox disease. Return to child care: Once the diagnosis has been made, determine the day that the blisters first appeared. The child may return to child care if all the lesions are crusted and dry and no new ones are forming. Keeping the child home until all the lesions are completely healed is unnecessary and results in excessive absences.

VII. Shingles (Varicella Zoster) Shingles (varicella zoster) is a reactivation of the chickenpox virus (varicella). After the initial infection with chickenpox, the virus continues to lie dormant (inactive) in a nerve root. We tend to think of the elderly and immunosuppressed individuals as the ones who have shingles; however, it can and does occur sometimes in children. The lesions or blisters of shingles resemble those of chickenpox and usually appear in just one area or on one side (unilateral) of the body and run along a nerve pathway. A mild shingles-like illness has been reported in healthy children who have had the chickenpox vaccine. This is a rare occurrence. Mode of transmission: It is possible for someone who has never had chickenpox disease or the vaccine to get chickenpox by coming in contact with the fluid from the lesions of someone who has shingles. Shingles itself is not transmissible. A person who has shingles does not transmit chickenpox through the air as does someone who has chickenpox disease. Return to child care: The child who has shingles may attend child care if the lesions can be covered by clothing. If the lesions cannot be covered, the child should be excluded until the

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lesions are crusted and dry. Staff members who have shingles pose little risk to others since the lesions would be covered by clothing or a dressing on exposed areas. Thorough hand washing is warranted whenever there is contact with the lesions. NOTE: Staff members, especially those who are pregnant, who have no history of chickenpox disease or chickenpox vaccine, should not take care of children with shingles during the time they have active or fluid-filled lesions.

VIII. Cytomegalovirus (CMV) CMV is a viral illness that most people become infected with during childhood. Small children usually have no symptoms when they become infected, but older children may develop an illness similar to mononucleosis with a fever, sore throat, malaise or feeling very tired and an enlarged liver. Mode of transmission: CMV is spread from person to person by direct contact with body fluids such as urine, saliva or blood. The virus can also be passed from the mother to the baby before birth. Pregnancy: Rarely, a woman may contract the disease for the first time during pregnancy which may pose a risk to the fetus causing certain birth defects. CDC recommends that women who are child care providers and who expect to become pregnant should be tested for antibodies to CMV and if the test shows no evidence of previous CMV infection, they should reduce their contact with infected children by working, at least temporarily, with children 2 years of age and older where there is less circulation of the virus. Also, they should avoid kissing an infected child on the lips, and as with any child care situation, wash hands thoroughly after each diaper change and contact with a child’s saliva. If contact with children does not involve exposure to saliva or urine, there should be no potential infection with CMV. Return to child care: There is no need to exclude children with CMV from child care as long as they do not have a fever since the virus may be excreted in urine and saliva for many months and may persist or there may be recurring episodes for several years following the initial infection. CMV is a virus that may persist as a latent infection and recur when a person becomes immunosuppressed with conditions such as cancer, AIDS, etc.

IX. Diarrheal Diseases (e.g., campylobacteriosis, cryptosporidiosis, giardiasis, rotavirus, salmonellosis, and shigellosis) – See STEC/E. coli O157:H7 and Hepatitis A sections for specific return-to-child-care recommendations regarding these two diseases.

Diarrhea is defined as frequent (3 or more episodes within a 24 hour period), runny, watery stools and can be caused by different types of organisms such as viruses, bacteria and parasites.

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Mode of transmission: Diarrheal diseases are generally transmitted or spread by ingesting food or water or by putting something in the mouth such as a toy that has been contaminated with the feces (stool) of an infected person or animal. In some cases such as with Salmonella and E. coli O157:H7, the disease is transmitted by eating raw or undercooked meats (especially ground beef and poultry) and unpasteurized milk and fruit juices. Notification: Notify parents/guardians of children in the involved room of the illness. Ask that any child with diarrhea, severe cramping or vomiting be evaluated by a physician and that parents should inform the day care of diarrheal illness in their child and family. Outbreak situation: Most diarrheal diseases are reportable to the Mississippi State Department of Health. When there are 2 or more cases of a diarrheal disease in one room, more extensive notification may need to be done and stool specimens may need to be collected. In this case, the director of the child care should consult with the Public Health District Epidemiology Nurse (available at: http://msdh.ms.gov/msdhsite/_static/19,0,166.htm) or the MSDH Office of Epidemiology at 601-576-7725. Return to child care: In most cases, a child may return to child care after a diarrheal illness once he or she is free of fever for 24 hours and the diarrhea has ceased with exception of Shiga toxin producing E.coli (STEC/E.coli O157).

X. Shigatoxin producing E. coli (STEC), including E.coli O157:H7 Escherichia (E.) coli bacteria are found in the intestines of most humans and many animals. These infections are usually harmless. However, certain strains of the bacteria such as the ones that produce shiga toxin such O157:H7 can cause severe illness. Some persons who are infected with E. coli O157:H7 or other STEC infections may have a mild disease while others develop a severe, bloody diarrhea. In some cases, the infection may cause a breakdown of the red blood cells which can lead to HUS or hemolytic uremic syndrome. Mode of transmission: STEC/E. coli O157:H7 is usually the result of eating undercooked meat, especially hamburger. There have also been cases reported from drinking unpasteurized apple juice. Person-to-person transmission may occur by contact with the feces or stool of an infected person. Notification: Notify the staff and parents/guardians that a case of STEC or E. coli O157:H7 has occurred and ask that they have their child evaluated by a physician if they have diarrhea, especially bloody diarrhea. STEC/E. coli O157:H7 are a Class I reportable disease and a follow-up investigation will be done by the Health Department. Return to child care: The infected child should NOT be in or allowed to return to a child care center until his/her diarrhea has ceased and 2 consecutive negative stool samples are obtained (collected not less than 24 hours apart and not sooner than 48 hours after the last dose of antibiotics).

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XI. Fifth Disease (Erythema Infectiosum) This is an infectious disease characterized by a “slapped –face” (redness) appearance of the cheeks followed by a rash on the trunk and extremities. Mode of transmission: Person-to-person spread by direct contact with nose and throat secretions of an infected person. Transmission of infection can be lessened by routine hygienic practices which include hand washing and the proper disposal of facial tissues containing respiratory secretions. Notification: Notify parents/guardians and staff members that fifth disease is occurring in the child care facility. Staff members who are pregnant should strictly avoid contact with any child with fifth disease. Return to child care: Children with fifth disease may attend child care if they are free of fever, since by the time the rash begins they are no longer contagious. The rash may come and go for several weeks.

XII. “Flu” (Influenza) Influenza is an acute (sudden onset) viral disease of the respiratory tract characterized by fever, headache, muscle aches, joint pain, malaise, nasal congestion, sore throat and cough. Influenza in children may be indistinguishable from diseases caused by other respiratory viruses. Mode of transmission: Direct contact with nose and throat secretions of someone who has influenza - airborne spread by these secretions coughed into the air. Return to child care: The child may return to child care when free of fever and feeling well. The closing of individual schools and child care centers has not proven to be an effective control measure. By the time absenteeism is high enough to warrant closing, it is too late to prevent spread. Key Points to Prevent the Spread of Flu in Child Care Settings

• Basic infection control in child care settings should always be promoted and maintained, not only during flu season. See the CDC Guidance for School Administrators to Help Reduce the Spread of Seasonal Influenza in K-12 Schools at http://www.cdc.gov/flu/school/guidance.htm

• Encourage students, parents, and staff to get a yearly flu vaccine—Teach students,

parents, and staff that the single best way to protect against the flu is to get vaccinated each flu season.

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• Stay home when sick—Those with flu-like illness should stay home until fever free for 24 hours without the use of fever-reducing medicines. They should stay home even if they are using antiviral drugs.

• Separate ill children and staff—Children and staff who appear to have flu-like illness

should be sent to a room separate from others until they can be sent home. CDC recommends that they wear a surgical mask, if possible, and that those who care for ill children and staff wear protective gear such as a mask.

• Hand hygiene--CDC recommends that children and staff be encouraged to wash their

hands often with soap and water, especially after coughing or sneezing.

• Respiratory etiquette— CDC recommends covering the nose and mouth with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available) and throwing the tissue in the trash after use.

• Routine cleaning—Child care staff should routinely clean areas that children and staff touch often with the cleaners they typically use. Special cleaning and disinfecting processes, including wiping down walls and ceilings, are not necessary or recommended. For guidance to slow the spread of flu in schools with cleaning and disinfecting, see http://www.cdc.gov/flu/pdf/freeresources/updated/cleaning_disinfecting_schools.pdf

XIII. Hand – Foot and Mouth Disease This is a common childhood disease caused by a strain of coxsackievirus. In some people, the virus causes mild to no symptoms. In others, it may result in painful blisters in the mouth and on the palms of the hands and the soles of the feet. Mode of transmission: The virus can be spread through saliva from the blisters in the mouth and from the fluid from the blisters on the hands and feet. It is also spread through the feces or stool of an infected person. Notification: Notify parents/guardians and staff that there are cases of hand-foot-and-mouth disease in the child care facility so that they can be alert to the signs and symptoms. Return to child care: The virus may be excreted in the stool for weeks after the symptoms have disappeared. Children who drool and have blisters in their mouths, or who have weeping or active lesions/blisters on their hands, should be excluded from child care until the lesions are crusted and dry and the child is free of fever for 24 hours.

XIV. Head Lice

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This is an infestation of the scalp by small insects called lice. They firmly attach egg sacs called “nits” to the hairs, and these nits are difficult to remove. Treatment may be accomplished with prescription or over-the-counter medicines applied to the scalp. Mode of transmission: Direct contact with an infested person’s hair (head-to-head) and, to a lesser extent, direct contact with their personal belongings, especially shared clothing and headgear. Head lice do not jump or fly from one person to another, but they can crawl very quickly when heads are touching. Notification: When a case of head lice occurs in a room, notify the parents/guardians that a case of head lice has occurred. Check the other children in that room for head lice and if found, notify their parents/guardians that the child needs treatment. Ask the parents/guardians to be alert to anyone in their family who may have signs and symptoms of head lice (e.g., excessive itching of the scalp, especially at the nape of the neck and around the ears) so that they may also receive treatment. Infants and children less than 2 yrs. of age: It is a rare occurrence for children in this age group to have head lice. It is generally not recommended to treat this age group prophylactically or just because someone else in the family has been treated. If a child in this age group is found to have head lice, the parent/guardian should consult the child’s physician for treatment recommendations. Return to child care: The child may return to child care after the first treatment has been given and the child is free of lice (live) and nits by visual inspection. (See Attachment A - “Recommendations for the Control of Head Lice in the Child Care Setting”)

XV. Hepatitis A This is an infectious viral disease characterized by jaundice (yellowing of the eyes and skin), loss of appetite, nausea, and general weakness. Child care centers can be a major source of hepatitis A spread in the community. This is because small children usually do not show any specific signs and symptoms of the disease. Symptomatic illness primarily occurs among adult contacts of infected, asymptomatic children. Mode of transmission: Hepatitis A virus is found in the stool of persons infected with hepatitis A. The virus is usually spread from person to person by putting fecal-oral contact with the stool of an infected person; for this reason, the virus is more easily spread under poor sanitary conditions, and when good personal hygiene, especially good hand washing, is not observed. Rarely, the virus is contracted by eating raw seafood (e.g., raw oysters) that has been collected from contaminated waters. Notification: Notify the staff and parents/guardians that a case has occurred. Hepatitis A is a Class 1 reportable disease. A follow-up investigation will be done by the MSDH to determine who in the center may need to receive preventive treatment.

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Return to child care: The child may return to child care one week after the onset of jaundice (yellowing of the eyes and skin) or one week after the onset of other signs and symptoms if no jaundice is present.

XVI. Hepatitis B Hepatitis B is a viral disease that affects the liver. It is a contagious condition characterized by loss of appetite, abdominal discomfort, jaundice (yellowing of the eyes and skin), joint aches, and fever in some cases. It is different from Hepatitis A. There should not be any risk of exposure to hepatitis B in a normal child care setting unless a child who is infected with hepatitis B is bleeding. Also, since the hepatitis B vaccine is now a part of the routine immunization schedule, more and more children should be immune. Mode of transmission: The most common mode of transmission is through having sex with someone who has the virus; however, it can be transmitted when infected blood enters the body through cuts, scrapes or other breaks in the skin. Injecting drug users are at risk when they share needles with an infected person. It is also possible for infected pregnant women to transmit the virus to their babies during pregnancy or at delivery. If an exposure to a person who is infected with hepatitis B has occurred, the person exposed should be referred to his/her physician since hepatitis B vaccine and hepatitis B immune globulin may be indicated. Since hepatitis B and HIV/AIDS are both transmitted through blood exposure, the precautionary measures for HIV/AIDS would also apply to hepatitis B. (See HIV/AIDS section below)

XVII. Hepatitis C Hepatitis C is also a viral disease that affects the liver. Again, hepatitis C should pose no risk of exposure in the normal child care setting unless the infected child is bleeding. There is no vaccine available for hepatitis C at this time. Since it is also transmitted through blood exposure, the same precautionary measures for hepatitis B and HIV/AIDS would be apply to hepatitis C. (See HIV/AIDS section below)

XVIII. Human Immunodeficiency Virus (HIV) Infection/Acquired Immunodeficiency Syndrome (AIDS)

Mode of transmission: The most common mode of transmission is through having sex with someone who has the virus; however, it can be transmitted when infected blood enters the body through cuts, scrapes or other breaks in the skin. Injecting drug users are at risk when they share needles with an infected person. It is also possible for infected pregnant women to transmit the virus to their babies during pregnancy or at delivery. Although HIV and hepatitis B are transmitted in the same way, HIV is much more difficult to transmit from one person to another than hepatitis B.

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HIV infection in children causes a wide range of symptoms and varied types of illness. Children with HIV infection should be monitored closely by their physician. They are more susceptible to infectious diseases than other children. Parents of children known to have HIV infection should be notified when certain infectious diseases occur in the child care facility. There is no vaccine available for HIV at this time. According to CDC, HIV is not likely to be spread from one child to another in the child care setting and no case has ever been reported. Parents or guardians of HIV-positive children should inform the child care director of their child’s HIV status. Because of concern over stigmatization, the person aware of a child’s HIV infection should be limited to those who need such knowledge to care for the children in the child care setting. In a situation where there is concern of possible exposure of others to the blood or body fluids of an infected person, CDC recommends that a team including the child’s parents or guardians, the child’s physician, public health personnel, and the proposed child care provider evaluate the situation to determine the most appropriate child care setting. The team should weigh the risks and benefits to both the infected child and to others in the child care setting. Because of the possibility that individuals may have an undiagnosed infection with HIV, hepatitis B and hepatitis C, universal precautions should always be employed (treating everyone’s blood as though it is infectious) when dealing with blood and body fluids. There is no evidence that HIV, hepatitis B or hepatitis C is transmitted through tears, perspiration, urine or saliva unless these body fluids contain visible blood. Child care providers should be prepared to handle blood and blood-containing body fluids using the principles of universal precautions. Supplies of gloves, disposable towels and disinfectants should be readily available. The Mississippi State Department of Health is available for consultation in these situations.

XIX. Impetigo This is a contagious bacterial infection characterized by spreading pustular lesions (sores with pus) and children should be evaluated for medical treatment. This is quite important to avoid the risk of complications involving the heart and kidneys. Mode of transmission: Skin-to-skin contact with the sores. Return to child care: The child may return to child care 24 hours after treatment has been started if free of fever and the lesions are not draining.

XX. Measles Measles is a serious viral infection characterized by a rash (red, flat lesions) starting on the head and neck, which enlarge and coalesce (run together), and spread to the trunk, then to the extremities. Other symptoms include a high fever, conjunctivitis (red, inflamed eyes), cough and nasal congestion. The Health Department must be notified on first suspicion. With our present

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immunization laws, measles is a rare occurrence today. It is imperative, however, that immunization records be kept current. Mode of transmission: Direct contact with nose and throat secretions of an infected person; may be airborne by droplets of these secretions coughed into the air. Tiny droplets can be suspended in the air for two hours or more. Measles is very easily spread. Notification: Notify staff and parents/guardians that a case has occurred. Measles is a Class I reportable disease and there will be a follow-up investigation by the Health Department. Parents of children with weakened immune systems (those being treated for cancer, leukemia or taking steroid medication, etc.) should consult their child’s physician and keep the child out of the center until after the investigation by the Health Department and it is considered safe for them to return. Return to child care: The child may return to child care when free of fever and the rash is fading (this usually takes 5-7 days).

XXI. Meningitis Meningitis is an inflammation or infection of the meninges (the membranes that cover the brain and spinal cord). Meningitis can be caused by a variety of organisms or germs. Most people exposed to these germs do not develop meningitis or serious illness. Some people may carry a particular germ and have no symptoms at all. Anyone exhibiting signs and symptoms of meningitis (e.g., severe headache, fever, vomiting, stiffness and pain in the neck, shoulders and back, drowsiness) should seek medical attention promptly. Meningitis is a reportable disease. The Department of Health evaluates each case individually to determine what public health intervention, if any, might be required. The two types of meningitis that most often require public health intervention are caused by the organisms Haemophilus influenzae type b (Hib) and Neisseria meningitidis (meningococcal). Mode of transmission: These germs are most commonly spread by direct contact with nose and throat secretions from an infected person. Notification: Notify parents/guardians that a case has occurred and to have their children evaluated by a physician should they have any of the signs or symptoms listed above. Return to child care: The child may return to the center whenever he or she has been released by his/her personal physician.

XXII. Molluscum Contagiosum This is a common skin infection that is caused by a virus. Most commonly, it affects children one to 10 years and young adults. Symptoms include small, pale, shiny, domed-shaped bumps on the skin, often with a characteristic dimple on the top. The bumps may be fleshed-colored,

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white, translucent, or pink. The bumps are usually painless, but on rare occasions, can be itchy, red, swollen, and/or sore. In children, the bumps occur on the face, body, arms, or legs. Mode of transmission: From direct skin-to-skin contact with an infected person. It can also be spread by contact with contaminated objects such as shared clothes, towels, wash cloths, gym or pool equipment, and wrestling mats. Return to child care: Molluscum contagiosum is not harmful and should not prevent the child from attending day care. Bumps should be covered with clothing where possible. Bumps not covered by clothing should be covered with a watertight bandage. Exclude any child with bumps that cannot be covered with a watertight bandage from participating in swimming or other contact sports.

XXIII. Mumps Mumps is an infectious disease that is characterized by swelling and pain of the salivary glands. Mode of transmission: Person- to- person spread by direct contact with the saliva of an infected person. Return to child care: The child may return to child care 9 days after the beginning of the salivary gland swelling.

XXIV. “Pink Eye” (Conjunctivitis) This is an infectious disease characterized by redness of the eye(s), excessive tearing, itching, and discharge. Some cases may require antibiotics; therefore, the child should see a physician. Mode of transmission: Contact with discharges from the eye, nose or throat of an infected person. Also, from contact with fingers, clothing and other articles that have been contaminated with the discharge. Return to child care: Children may return to child care after they have seen a physician or when the redness/discharge is improving.

XXV. Pinworms Pinworms are tiny worms that live in the large intestine and can cause anal itching, sleeplessness and irritability. They may also be present without any symptoms. Pinworms occur worldwide and affect all socioeconomic classes. They are the most common worm infection in the United States. Prescription medication must be obtained to treat the infection. Mode of transmission: Pinworms can be spread when an uninfected person touches the anal area of an infected person and then puts their hands/fingers in their mouth. They can also be spread when an infected person scratches the anal area and then contaminates food or other

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objects that are touched or eaten. Pinworms can be spread as long as the worms or the eggs are present. Return to child care: The child may return to child care 24 hours after they have received the first treatment. Employ thorough hand washing especially before eating and after toilet use and change and wash any bed linens and towels in hot water that have been used for those children. Ask the parents/guardians to do the same at home. Also, discourage children from scratching the anal area.

XXVI. Respiratory Syncytial Virus (RSV) RSV can cause an upper respiratory disease, like a cold or lower respiratory tract disease such as pneumonia. It is the most common cause of lower respiratory tract infections and pneumonia in infants and children under the age of 2 years. Almost 100% of children in child care programs get RSV during the first year of life. This usually occurs during outbreaks in the winter months. RSV can range from a very mild disease to life-threatening. Mode of transmission: Direct contact with nose and throat secretions of an infected person. A young child can be infectious with RSV 1 to 3 weeks after signs and symptoms have subsided. Return to child care: Most of the time a child is infectious before signs and symptoms appear. An infected child does not need to be excluded from child care unless he/she has a fever and/or is not well enough to participate in the activities. Make sure that procedures pertaining to hand washing, proper disposal of tissues and disinfection of toys are followed.

XXVII. Ringworm Ringworm is a skin infection caused by a fungus that can affect the scalp, skin, fingers, toe nails and feet. Ringworm (except on the scalp or under the nails) can be successfully treated with several over-the-counter medicines. Ringworm of the scalp is characterized by inflammation, redness, and hair loss and does not respond to over-the-counter medicines; therefore, the child should see his/her physician. Mode of transmission: Direct skin-to-skin contact or indirect contact (e.g., toilet articles such as combs and hair brushes, used towels, clothing and hats contaminated with hair from infected persons or animals). Notification: When the lesions (red, circular places) are found, notify the parent/guardian that the child needs treatment. Return to child care: The child may return to child care after the treatment has been started. Treatment for ringworm of the scalp and nails usually lasts for several weeks. Strict infection control measures should be taken (e.g., blankets, towels or anything that is used on the infected child should not be used on another child, make sure that staff caring for these children practice good hand washing and that disinfecting procedures are followed.

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XXVIII. Scabies

Scabies is a disease of the skin caused by a mite. The mite burrows beneath the skin and causes a rash that is usually found around finger webs, wrists and elbows. The rash may appear on the head, neck and body on infants. Any child with evidence of severe itching especially in these areas should be referred to his/her physician. Scabies requires treatment by prescription drugs. Mode of transmission: Direct skin-to-skin contact with an infested person. Transfer of the mites from undergarments and bedclothes can occur, but only if contact takes place immediately after the infested person has been in contact with the undergarments and bedclothes. Notification: Notify parents/guardians and staff that scabies has occurred in the facility so that they can be alert to signs and symptoms and seek treatment. Return to child care: The child may return to child care 24 hours after the treatment has been completed. It must be noted that itching may continue for several days, but this does not indicate treatment failure or that the child should be sent home.

XXIX. “Staph” (Staphylococcal Infections) Staphylococcus aureus, usually referred to as “staph” is a type of bacteria that anyone can carry in the nose or on the skin. Staph commonly causes skin infections that look like pimples; though all pimples and skin infections are not caused by staph. These infections are generally minor and resolve without prescription medication. Staph can cause more serious skin infections that are swollen, painful and have purulent (pus) drainage. In addition to skin infections, staph bacteria can cause infections in the blood, the lungs (pneumonia) or anywhere in the body. These more serious infections require medical evaluation and treatment. According to the Centers for Disease Control (CDC), over the past 50 years, some staph bacteria have become resistant to antibiotics, including the commonly used penicillin-related antibiotics. These resistant bacteria are called methicillin-resistant Staphylococcus aureus, or MRSA. Due to the resistance, MRSA infections are more difficult to treat. Mode of transmission: Direct skin-to-skin contact with a draining lesion/sore or purulent (pus) discharge. Staph may also be spread by contact with articles soiled with discharge or drainage (e.g., tissues, Band-Aids, etc.). Airborne spread is rare, but can occur with those who have a respiratory disease. Return to child care: Children who have a minor staph infection of the skin such as a pimple may attend child care. Those who have a more serious staph infection that requires medical treatment should not return to child care until 24 hours after treatment has been started and is free of fever. Any lesions that are oozing and are on exposed skin surfaces should be covered with a leak-proof bandage. The same exclusion criteria would apply to those who have been diagnosed with a MRSA infection.

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XXX. “Strep Throat” (Streptococcal Pharyngitis) & Scarlet Fever

Strep throat (caused by Group A streptococcal bacteria) is a disease characterized by sore throat, fever, and tender, swollen lymph glands in the neck. The child should see a physician to obtain prescription medication; this is quite important to avoid the risk of complications involving the heart and kidneys. Scarlet fever is a streptococcal infection with a rash (scarlatiniform rash). It is most commonly associated with strep throat. In addition to the signs and symptoms of strep throat, the person with scarlet fever has an inflamed, sandpaper-like rash and sometimes a very red or “strawberry” tongue. The rash is due to a toxin produced by the infecting strain of bacteria. Both the treatment and exclusion criteria for scarlet fever would be the same as for strep throat. Mode of transmission: Direct or indirect contact (e.g., contaminated hands, drinking glasses, straws) with throat secretions of an infected person. Return to child care: The child may return to child care 24 hours after treatment has been started if free of fever.

XXXI. Tuberculosis (TB) Mode of transmission: Airborne droplets of respiratory secretions coughed or sneezed into the air by a person with active TB disease. Notification: TB is a class 1 reportable disease. If a child or a staff member in a child care facility is diagnosed with active TB, the MSDH will conduct an investigation. The MSDH will notify the facility and the parents/guardians of the type of follow-up that will be necessary. Return to child care: Persons diagnosed with TB infection are evaluated by the Mississippi State Department of Health on an individual basis. Those who have a positive TB skin test only may attend child care since they have no disease process that is contagious. Persons suspected of or diagnosed with active TB disease will need written permission from the Mississippi State Department of Health Tuberculosis Control Program to return to the center. Small children are highly susceptible to contracting TB disease, but do not transmit the disease as easily as an older child or adult. Children who do not have active TB disease, but who have been exposed to an active case in their household are considered high risk contacts and are placed on preventive medication. These children may attend child care since they are not infectious.

XXXII. Whooping Cough (Pertussis) Pertussis or whooping cough is a contagious disease characterized by upper respiratory tract symptoms with a cough, often with a characteristic inspiratory (breathing in) whoop.

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Mode of transmission: Direct or indirect contact (contaminated articles) with nose and throat secretions of an infected person. Airborne transmission can also occur by droplets of these secretions coughed into the air. Notification: Notify parents/guardians that a case has occurred. Pertussis is a class I reportable disease. The Health Department will conduct an investigation to determine those who may need preventive treatment. Return to child care: The child may return to child care 5 days after their treatment has begun.

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EXAMPLE

XXXIII. Permission to collect stool specimens and receive test results If and when an outbreak of diarrheal diseases such as giardiasis, salmonellosis, shigellosis, etc. occurs in a child care facility, the Mississippi State Department (MSDH) investigates and may request that stool specimens be collected. In an outbreak situation, the stool specimen collection bottles are provided by the MSDH and the tests are done in the MSDH Lab free of charge. The collection bottle, with instructions, would either be given to the parent/guardian to collect the stool specimen or it may need to be collected at the child care facility. The child care facility would receive the test results and recommendations would be made by the MSDH. The test results would be given to the parents/guardians by the child care facility and the parents/guardians should give them to their child’s physician. I give my permission for (name of child care facility) to collect stool specimens from (name of child) when it is recommended by the MSDH and also for them to receive the test results. I understand that I will receive a copy of the test results and be informed of the recommendations made by the MSDH. Date Parent/Guardian

XXXIV. Mississippi State Department of Health Public Health Districts

Public Health Districts Northwest Public Health District I 662.563.5603

Northeast Public Health District II 662.841.9015

Delta/Hills Public Health District III 662.453.4563

Tombigbee Public Health District IV 662.323.7313

West Central Public Health District V 601.978.7864

East Central Public Health District VI 601.482.3171

Southwest Public Health District VII 601.684.9411

Southeast Public Health District VIII 601.544.6766

Coastal Plains Public Health District IX 228.436.6770

A. Appendix A: Recommendations for the Control of Head Lice in the Childcare Setting

I. Introduction

Head lice, Pediculus humanus capitis, can be common problem among children who attend child care. Although they do not transmit any human disease, they may be a considerable nuisance, and require conscious effort on the part of childcare officials and parents to control. The Mississippi State Department of Health (MSDH) has developed these recommendations to provide childcare facilities with a standardized approach for the detection and management of a student identified with head lice infestation and to outline the role of MSDH. Resources:

• MSDH website: http://msdh.ms.gov/msdhsite/_static/14,0,119,642.html • The Centers for Disease Control and Prevention (CDC):

http://www.cdc.gov/parasites/lice/head/. • Specific CDC recommendations for schools:

http://www.cdc.gov/parasites/lice/head/schools.html • Specific CDC recommendations for parents:

http://www.cdc.gov/parasites/lice/head/parents.html

II. How Lice are Spread Head lice are spread by direct contact to the hair of an infested person, mainly by head-to-head contact with a person who has head lice. Head lice do not fly or hop to another person, direct contact is required. Spread by contact with clothing (such as hats, scarves, coats) or other personal items (such as combs, brushes, or towels) used by an infested person occurs, but less frequently. Head lice are not a product of poor personal hygiene or lack of cleanliness, and their presence is not a reflection on the childcare or the family. More harm is probably caused by misconceptions about head lice than by the lice themselves.

III. Identifying Infested Children The diagnosis of head lice infestation is best made by direct examination of the hair and scalp. Finding a live nymph or adult louse is an indication of head lice infestation. If crawling lice are not seen, finding nits (lice eggs) a within ¼ inch of the base of hair shafts suggests, but does not confirm, the person is infested. Lice infestation can be identified in children in the childcare setting by implementing a routine screening process at the childcare, or by individual examination of the scalp of a child suspected of lice infestation. a. Routine Screening: It is important to establish a regularly scheduled screening program for

all children in the childcare setting. Children should be screened upon entry into the daycare and periodically throughout the year. Staff members should be instructed in the detection of head lice.

b. Suspected Case: Throughout the year, any child suspected of having head lice should be

examined by a staff member who has been instructed in the detection of head lice. Signs or symptoms in the child may include a sensation of movement in the hair, frequently scratching his/her head or increased irritability and sleeplessness in young children. If

infested, the child should be handled as described in the section “Handling of Infested Children”.

c. Additional Screening: should occur more often if infested children are found in the childcare. If one child in a classroom is found to be infested, it is recommended that the whole class should be screened as described above.

IV. Handling of Identified Infested Children a. Initial Exclusion: Once identified, an infested child’s parent/guardians should be notified

that the child has been found to have head lice and must receive the proper treatment before returning to the childcare. It is not necessary to remove the infested child from the childcare before the end of the day. Care must be taken not to embarrass or stigmatize the child.

b. Return to Childcare: The child should be allowed to return to childcare as soon as the parent/guardian provides evidence of treatment, such as a note describing the treatment or by presenting the empty bottle of the product used with the label intact. The treatment should be an approved medical treatment and not a home remedy (see http://www.cdc.gov/parasites/lice/head/treatment.html for CDC recommended treatments).

V. “No-Nit Policy” Not Recommended for Return to Childcare

No-Nit policies are not advocated as a method of the prevention of spread of lice within the childcare setting. Nits (eggs) may still be seen even in an adequately treated child, and is not evidence of continuing infestation if the child has been properly treated and no adult lice are present (successful treatment should kill crawling lice).

MSDH does not dictate childcare policy. Individual childcare facilities should set their own policies concerning the presence of nits and return to the childcare facility after treatment. MSDH is available for consultation.

VI. Treatment Recommendations

Treatment is recommended for all students diagnosed with an active infestation. See the Centers for Disease control and Prevention at http://www.cdc.gov/parasites/lice/head/treatment.html for full treatment guidelines. MSDH website provides a link to the CDC website at http://msdh.ms.gov/msdhsite/_static/14,0,119,642.html.

General treatment recommendations from CDC include: • Treatment requires using an Over-the-counter (OTC) or prescription medication; • All recommendations pertaining to the selected treatment should be followed;

Examination of a treated child by a physician or the Mississippi State Department of Health is usually not indicated and unnecessarily involves health care personnel.

The American Academy of Pediatrics (AAP) and the National Association of School Nurses (NASN) advocate that "no-nit" policies should be discontinued. See the Centers for Disease Control and Prevention (CDC) “Head Lice Information for Schools” available at http://www.cdc.gov/parasites/lice/head/schools.html.

• A second treatment in 9-10 days is recommended when using OTC treatments; • Nits (eggs) may persist after treatment. Successful treatment should kill crawling lice, but

removal of all nits is not necessary; • Treatment for all persons with active infestation is necessary; • Treatment of household members with active infestation is necessary; • Treatment for persons who share the same bed with actively infested persons is necessary; • CDC also has an FAQ for Head Lice Treatment available at

http://www.cdc.gov/parasites/lice/head/gen_info/faqs_treat.html. Family: Household members of a student with head lice should be examined for lice (by a family member who knows how or someone else knowledgeable about lice) and any infested persons treated. VII. Environmental Control

Household: • Clothing, cloth toys, and personal linens (such as towels and bedclothes used within the

previous 48 hours by an infested person) can be disinfected by washing in hot water and drying in the dryer using hot cycles.

• Non-washables should be dry cleaned, or stored in air-tight plastic bags for 2 weeks. • Spraying with insecticides is usually not necessary. • If there are cloth surfaces, such as furniture or carpet, with which the infested person's

hair has had extensive contact, they should be vacuumed thoroughly.

Childcare setting: • Children should not be allowed to share hair ornaments, brushes or combs. • Hats, coats, scarves and the like should be hung or placed individually for each child and

not stacked or hung on top of those belonging to other children. Wall hooks, if used, should be far enough apart that garments hung on adjacent hooks do not touch.

• Headgear, including headsets, should be removed from use if lice are present in the class. If lice are an ongoing problem, headgear and headsets should be stored in an air-tight plastic bag for 2 weeks and not reused until the problem is resolved.

• Carpeted areas in classrooms should be vacuumed frequently and thoroughly. Lice killing sprays are generally unnecessary.

• Fumigation of classrooms or buses is not indicated. VIII. Role of the Health Department

Questions about control methods, specific treatments, or special problems can be addressed to the local health department, the district public health office, or to the Office of Epidemiology.